Healthcare Provider Details

I. General information

NPI: 1972054104
Provider Name (Legal Business Name): BRIAN RICHARD LAZZARO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 S WESTERN AVE
PARK RIDGE IL
60068-3820
US

IV. Provider business mailing address

325 S WESTERN AVE
PARK RIDGE IL
60068-3820
US

V. Phone/Fax

Practice location:
  • Phone: 847-712-1445
  • Fax:
Mailing address:
  • Phone: 847-712-1445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009356
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: